Human Trafficking and Health Care Providers’ Role in Recognition

Abstract

Human trafficking is a grave public health concern globally, with thousands to millions of individuals being trafficked worldwide every year, including women and children. Health care workers hold a unique place in fighting this menace by recognizing and caring for victims of human trafficking. Health care workers have a high probability of interacting with the victims of human trafficking, primarily in urgent care environments. This study looks into an overview of human trafficking risk factors and red flags in the U.S. and globally and the role health workers play in the process, particularly in recognizing and caring for trafficked victims. The role of health care providers to be examined includes recognition/identification of human trafficking and trafficked victims, treatment, formulation of a plan of care, including trauma-informed care, and culture sensitivity when interacting with victims of human trafficking.

Significance of the Problem

Human trafficking is the recruitment, transfers, transportation, harboring, and receipts of people through force, deception or fraud to exploit them for profit. Human trafficking is a criminal activity encompassing the taking advantage of people for compelled profit-making sex or labor using coercion, force, or fraud and is a pressing issue globally and even in the U.S. (Donahue,  Schwien,  & LaVallee, 2019). Even though human traffic is not easy to quantify due to the secretive nature of the activity and lack of comprehensive data, it is approximated that about 800,000-1,000,000 individuals are trafficked worldwide every year. Of those trafficked, about 80% are girls or women, 50% are minors (Moreno, 2015). Data by the U.S. National Human Trafficking Hotline reports 22,326 recognized victims of human trafficking in 2019 alone, of which 14,597 were sex trafficking survivors/victims, 4,934 labor victims/survivors, 1,048 labour and sex victims, and 1,747 unspecified. The report further notes that a total of 63,380 incidences of human trafficking were recognized through the trafficking hotlines between 2007 and 2017 (U.S. Department of Health & Human Services, 2019). According to FBI estimates, an estimated 100,000 domestic minors are sold for sex every year in the U.S., while researchers show a higher figure (Liles, Blacker, Landini, & Urquiza, 2016). The data reveal how serious the subject of human trafficking is, both in the U.S. and globally, and requires an immediate address. Human trafficking is a severe public health challenge globally. Human trafficking has both mental and physical health implications. From physical torture and sexual abuse of victims to emotional trauma, the impact on the individuals is destructive and unacceptable. Many victims get infected with STIs and HIV, while some are forced to carry out abortions (Daniel-Wrabetz & Penedo, 2015). Health care workers are among the few experts most likely to encounter trafficked girls and women when still in transit or captivity (Donahue, Schwien, & LaVallee, 2019). Research indicates that about 28% of trafficked girls and women interacted with health care experts while still in confinement—this is an unexploited opportunity for interventions. Healthcare providers are uniquely placed on establishing and helping victims of human trafficking because of the high probability that they will interact with the victims, mostly in urgent care environments (Titchen et al., 2017). This research explores human trafficking and the health care providers’ role in recognizing and assisting victims of human trafficking.

Literature Review

Gyawali, Keeling, and Kallestrup (2017) argue that human trafficking is just like any other market-driven criminal industry, such as arms trafficking and drugs, operating on the principle of demand and supply. However, other factors such as disasters make both adults and children more vulnerable to human trafficking. Disasters cause chaos, disrupting systems that protect humans. It may cause children to separate from their parents, create a new market for cheap labor, or opt for survival tactics that increase traffic risk. Schwarz et al. (2016) also pointed out several risk factors that push individuals toward trafficking, including lack of education, poverty, English language barrier/limitation, gender inequality, addiction, LGBTQ status, homelessness, childhood abuse or trauma. It is crucial to note that the presence of the factors does not automatically imply that trafficking will happen. Hadjipanayis, Crawley, Stiris, Neubauer and Michaud (2018) assert that people can live in abject poverty or be homeless without being trafficked. However, the presence of manifold of these risk factors drives individuals on the way to exploitation and human trafficking. When individuals are marginalized along numerous axes, where numerous structural disparities converge, their risks of being trafficked increase. Human trafficking criminals exploit such situations to their benefit.

Women and girls are the vast percentages of trafficked victims. About 80% of trafficked victims are girls or women, and 50% are minors (Moreno, 2015). However, the women do not identify themselves as victims of human trafficking because their traffickers often accompany them to healthcare facilities. Some are also shamed by the trafficking experience of trafficking or fear their families could be harmed if they speak up or due to Stockholm syndrome, occurring when the victim has established positive feelings concerning the trafficker (Costa et al. 2019). The health sector in the U.S. has a firm commitment to stopping violence against women by establishing the potential trafficking victims through greater awareness.

Research has proposed several red flags that health care professionals can use to recognize trafficked persons and administer the appropriate intervention. According to Scannell, MacDonald, Berger, and Boyer (2018), whereas risk factors make individuals susceptible or exposed to human trafficking, red flags show that trafficking might have happened or is continuing. Some of the most common red flags are particular health presentations such as untreated sexually transmitted diseases (STDs or STIs) or patients being accompanied by a controlling individual such as a partner, employer or person claiming to be a family member when presented for “on-the-job” injuries. A red flag is also possible for patients lacking personal documentation or identifications or unsure of their locations. The existence of such red flags should prompt intervention.

(Kennedy, Arebalos, Ekroos, and Cimino (2021) maintained that the lack of prevalent training across the board builds a gap between the manifestation of a red flag and recognition as a sign of human trafficking and potential intervention by health care professionals. Trafficked individuals access healthcare facilities for different health presentations such as physical injuries, STIs, anxiety, PSTD, burns, suicidal ideation, substance abuse, abortion complications, HIV/AIDs, sexual violence, depression, skin condition, and many other complications. Even though physical health results are the most recognized and documented, trafficked persons also suffer predominantly from mental health issues due to the intense psychological damages resulting from traumatic events and somatic complaints that often turn into dysfunction or physical pain (Scannell, MacDonald, Berger, & Boyer, 2018). Health care professionals are crucial partners in combating and stopping human trafficking during and post-emergency events, even if they may not have realized their vital role in this fight.

On healthcare professionals’ role in recognizing human trafficking, Gyawali, Keeling, and Kallestrup (2017) noted that healthcare workers are uniquely positioned to recognize the red flags and intervene appropriately. Studies now indicate that many trafficked people interact with the medical sector. This is contrary to widely health perception that trafficked people are a hidden population because of the criminal nature of human trafficking. The encounters are not limited to a single medical environment; trafficked people interact with health care workers in hospitals, emergency rooms, clinical treatment facilities, and private physician levels. Lederer and Wetzel (2014) argued that there is a high likelihood that trafficking victims can talk to medical professionals than the police. Hence, the presence of human trafficking red flags is a perfect intervention point to trigger recognition and services.

Furthermore, considering that risk factors such as disasters increase the risks linked to human trafficking, health care providers, including nurses, physicians, and emergency service professionals offering care for survivors during and post disasters are more likely to encounter individuals being or have been trafficked (Hadjipanayis et al. 2018). Studies have indicated that 50% of trafficking victims interacted with health care providers while in captivity, even outside a disaster. Nevertheless, most health care workers, particularly physicians and even nurses, are not trained to recognize such victims, notwithstanding their reasonable opportunity to intervene. Hence, become aware of the issues and response mechanisms, health care workers working in and outside disaster contexts have the potential to prevent continued victimization caused by the cruel acts of human trafficking (Gyawali, Keeling, & Kallestrup, 2017).

Nevertheless, Scannell, MacDonald, Berger, and Boyer (2018) observed that recognizing possible trafficked victims is challenging since they seldom self-identify. The health set also lacks clinically certified screening tools to screen such victims. The researchers argued that even if the trafficked victims tell about their experiences, the health care professionals may not understand the danger or complexity of their situations. Although several health bodies, including the American College of Obstetrics and Gynecologists and the American Academy of Pediatrics, have emphasized education concerning human trafficking, there is still an absence of standardized, formal, evidence-based training for health care experts on human trafficking. Grace, Ahn, and Konstantopoulos (2014) argued that the need for such training levels is principally high among health care professionals operating in the emergency sections. Professionals in the emergency room often care for disenfranchised groups and are better placed than other health care workers to encounter trafficking victims. One research by Hadjipanayis et al. (2018) on sex trafficking victims and survivors established that 63.3% of the respondents seek treatment services in the healthcare emergency room. Patients visiting the emergency rooms are, in most cases, in vulnerable situations. Hence, extending their screening to include exploited and trafficked persons is a critical step to ensuring such people’s rights to healthcare and protection from criminal exploitation (Lederer & Wetzel, 2014)

One study established that health complications common in victims of human trafficking are principally owing to numerous factors, including deprivation of sleep and food, dangers of travel, extreme stress, and highly dangerous work. Since most trafficking victims may not access health care early enough, they often reach a health professional when their problem is advanced (Recknor, Gemeinhardt, & Selwyn, 2018). The victims are at the risk of multiple STIs and sequelae of multiple forced abortions. Besides, physical torture leads to fractured bones, dental complications, contusions, and cigarette burns. Emotional trauma leads to suicidal ideation/thoughts, substance addiction, depression, and somatic symptoms (Scannell, MacDonald, Berger, & Boyer, 2018). When health care workers were queried in one study concerning their experience managing human trafficking victims, they stated that most victims are lonelier, unstable, exhibit a high level of fear, and have higher mental health needs and trauma than victims or survivors other crimes. One victim of human trafficking can take a similar healthcare professional’s time as 20 or more victims of domestic violence (Powell, Asbill, Louis, & Stoklosa, 2018).

Differential Diagnosis

The “Campaign to Rescue and Restore Victims of Human Trafficking (CRRVHT)” by the U.S. Department of Health and Human Services provide an outline for responding to healthcare needs for victims of human trafficking and include identification/recognition, treatment, and making a plan of care as discussed in the following section:

On identification or recognition,CRRVHT lists potential clues that an individual may be a victim of human trafficking, some of which have been discussed earlier in this paper. They include:

• Evidence of the patient being controlled
• Evidence of the person not moving or leaving a job
• Evidence of buttering or bruises
• Deportation fears
• Recently travelled/ brought to the country
• Absence of essential identification documents such as a passport.

Review of Diagnostics

Health care professionals can apply these clues to identify or recognize victims of human trafficking. Even though the list can be adopted for several other problems, such as domestic violence, they show the reason for additional examination by healthcare providers (U.S. Department of Health and Human Services 2011). Further studies have shown that victims of trafficking are more likely to fear authority persons and will be unwilling to provide personal information. Hence, questioning the patient may prove a challenging task for the providers (Recknor, Gemeinhardt, & Selwyn, 2018). The first step to ensure the encounter successfully gets the patient alone, as most of them are always accompanied by another person. If necessary, the provider should find an interpreter and strive to build a rapport with the patient. Likely, the client will not be willing to provide personal information or identify themselves as trafficking victims; hence the healthcare provider must pay attention to nonverbal and subtle cues (Coppola & Cantwell, 2016). Once the victim has been recognized, the next thing should be treated.

Discussion of Holistic Management: Providers’ Role and Approach

Holistic management refers to health care interventions based on the mutual understanding of the patient’s psychological, physical, spiritual, and emotional dimensions (Feo, Kitson & Conroy, 2018). Treatment for physical and emotional health forms part of an essential intervention by the healthcare professional upon recognizing trafficked victims as provided for by the CRRVHT providers (U.S. Department of Health and Human Services 2011). The health care provider should respond to immediate needs such as treatment of STIs, physical trauma, assessment of suicidal ideation, and pregnancy diagnosis. However, responding to every victim’s emotional and physical requirements is beyond the core of the individual health care professional’s practice as the victim will require long-term care administered by an interdisciplinary team of health experts (Grace et al. 2014). However, some researchers have advocated for the need to provide comprehensive needs assessments to establish multiple social and health care needs the client faces (Macias-Konstantopoulos, 2016). Providing a quick response to trafficked individuals’ immediate mental health, physical health, accommodation and general safety has been emphasized by many researchers. A needs assessment has also been emphasized to establish potential long-term health complications and immediate needs (Hemmings et al., 2016).

Once the victim of human trafficking has been recognized, the health care professional and the client should draw up a care plan. However, the provider must take note of the following: a) they cannot pressure the victims/client to report the crime; and b) the victims and even their family can be in great danger if they report the crime. However, the provider is lawfully indebted to call child protective services if the victim is a minor (U.S. Department of Health and Human Services 2011). Macias-Konstantopoulos (2016) noted that care plans should be victim-specific. Nevertheless, the professional should consider contacting the “National Human Trafficking Resource Center” through the national referral line. This can help find local resources for the trafficked victims and create an acceptable safety plan for the client.

Coppola and Cantwell (2016) argue that since the victim has already experienced substantial helplessness, the provider should consider this an opportunity to offer the customer some decision-making abilities. For instance, the health care worker and the victim can contact the national referral anonymously, asking questions concerning the victim’s situation. Alternatively, the provider can provide the clients with the contact details and a safe space to make the calls themselves. Healthcare providers are not obligated by law to make a call to anyone, law enforcement or referral line unless the victim is a minor. The providers are also not advised to make any formal report minus the client’s accord, even if they anonymously call the referral (Scannell, MacDonald, Berger, & Boyer, 2018). However, human trafficking victims’ identification and reporting are still grey areas without much clear information and guidelines, and the health care provider may sometimes make their moral decisions concerning reporting suspected human trafficking.

If the victims happen to contact the national referral line (National Human Trafficking Resource Center) themselves or with the provider’s help, the client can be helped to get to a safe location. As soon as they are in a safe place, they can decide to partake in the certification process. The certification is an element of the “Victims of Trafficking and Violence Protection Act” helping trafficked victims acquire the necessary documentation to help them legally stay in the U.S. and get assistance from state or federal programs (Scannell, MacDonald, Berger, & Boyer, 2018). The victim may have to apply for the certification if they are minors or already citizens of the U.S., as that is already eligible to stay in the country and receive the benefits. Federally funded benefits and services include witness protection, health care, translation, job training, legal representation, access to housing, and transportation. However, the victims can only be certified if they satisfy the following criteria: a) are victims of trafficking; b) are prepared to help in investigating and prosecuting the human trafficking situation; c) has requested the T visa (U.S. Department of Health & Human Services 2021).

Research has shown that when trafficking victims are undocumented, deportation becomes a significant concern and potential obstacle to reporting criminal activities. Responding to this concern, the U.S. Department of Justice developed a trafficking visa (T visa) to help the victims and possibly include families to legally stay in the U.S. if they comply with the requirements for help in the investigation and prosecution of related trafficking offences. T visa allows the recipient to be legally employed and become permanent residents of the U.S. after three years (Stevens, & Berishaj, 2016). However, the provider is advised not to promise the victims concerning immigration status as there is still the possibility that the undocumented immigrant can still be denied a visa with the T visa (Stevens, & Berishaj, 2016).

Part of the care plan also incorporates trauma-informed care. Several studies have emphasized the significance of adhering to a trauma-informed care approach when providing care for trafficked individuals (Abas et al., 2013; Hemmings et al., 2016). Trauma-informed care encompasses a commitment to victim safety and empowerment and recognizes the influence of numerous traumatic events in the person’s life course (Hemmings et al. 2016). Some researchers have highlighted the significance of avoiding re-traumatization, such as ensuring that trafficking survivors are not forced to discuss the details of the trafficking event when they do not feel ready (Recknor, Gemeinhardt, & Selwyn, 2018; Coppola, & Cantwell, 2016). The provider must let the client only talk about the incident when they are willing without coercion.

            The care plan should also include culturally sensitive interaction between the health care providers and the victim. Powell, Asbill, Louis, and Stoklosa (2018) argued that the significance of establishing a culturally excellent and competent service for human trafficked victims is another critical area for health care providers. Culturally sensitive care is defined as the provision of care by considering how individuals from diverse cultures or backgrounds express or experience illness and their response to care. In particular, some researchers have focused on cultural diversities in peoples’ attitudes towards some aspects of health, most so mental health. Some western approaches, including counselling, have been ruled out when interacting with these clients. In one study, the victims considered other services besides one-to-one therapy to cater for their emotional needs, including acupuncture. They termed their experiences with one-to-one as blaming and shameful, and the western talk therapy conflicted with their cultural backgrounds (Salami et al., 2021; Scannell, MacDonald, Berger, & Boyer, 2018). This makes culturally sensitive a pertinent area of concern by health care professionals when interacting with trafficked victims.

Summary Statement

            Overall, human trafficking is a serious health challenge globally, one that health professionals must not overlook. Health care experts are uniquely placed to interact with some trafficked victims, even though if not all of them during the treatment of STIs, abortion services, and other services. Hence, health care providers should be appropriately trained to recognize, treat, and help trafficked victims as a component of their everyday clinical practice.